Experiences, barriers, and facilitators of health data use among performance monitoring teams (PMT) of health facilities in Eastern Ethiopia: A qualitative study

Background Routine health data is crucial in decision-making and improved health outcomes. Despite the significant investments in improving Ethiopia’s Performance Monitoring Team (PMT), there is limited evidence on the involvement, implementation strategies, and facilitators and barriers to data utilization by these teams responding to present and emerging health challenges. Therefore, this study aimed to explore the PMT experiences, facilitators, and barriers to information use in healthcare facilities in Eastern Ethiopia. Method This study employed a phenomenological study design using the Consolidated Framework for Implementation Research (CFIR) to identify the most relevant constructs, aiming to describe the data use approaches at six facilities in Dire Dawa and Harari regions in July 2021. Key informant interviews were conducted among 18 purposively selected experts using a semi-structured interview guide. Thematic coding analysis was applied using a partially deductive approach informed by previous studies and an inductive technique with the creation of new emerging themes. Data were analyzed thematically using ATLAS.ti. Results Study participants felt the primary function of PMT was improving health service delivery. This study also revealed that data quality, performance, service quality, and improvement strategies were among the major focus areas of the PMT. Data use by the PMT was affected by poor data quality, absence of accountability, and lack of recognition for outstanding performance. In addition, the engagement of PMT members on multiple committees negatively impacted data use leading to inadequate follow-up of PMT activities, weariness, and insufficient time to complete responsibilities. Conclusion Performance monitoring teams in the health facilities were established and functioning according to the national standard. However, barriers to operative data use included PMT engagement with multiple committees, poor data quality, lack of accountability, and poor documentation practices. Addressing the potential barriers by leveraging the PMT and existing structures have the potential to improve data use and health service performance.


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The ethical approval and clearance for this research was obtained from Institutional Health Research Ethics Review Committee (IHRERC) of Haramaya University with reference number IHRERC/196/2020. Permission was sought from regional health bureaus and the health facilities. Before data collection, informed written consent was obtained from the study participants after explaining the study aims and their right to withdraw from the study at any time. If the data are held or will be held in a public repository, include URLs, accession numbers or DOIs. If this information will only be available after acceptance, indicate this by ticking the box below. For example: All XXX files are available from the XXX database (accession number(s) XXX, XXX.).
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Introduction
Health systems are complex and continually changing to adapt to changing political, economic, social, technological, and epidemiological realities within constrained resources, particularly in Low-and Middle-Income Countries (LMICs). (1-3) Health facilities need to cope with these changing realities through organized management and leadership, which require use of reliable data for the development of a comprehensive policy package for health sector reforms; improving planning and continuous monitoring. (2,4) There has been an increased need for strengthening health service performance to manage population needs through effective leadership (5-7) and improved health facility data use culture.
(8-10) The increasing demand for and capacity to use data appears more important than the augmenting supply of evidence (3,13) for improved access to and quality of care. (4,14) Collection, processing, transforming, communicating, and using service delivery reports and administrative records play a crucial role in decisions towards improved health outcomes. (15,16) Data use is the process through which decisions-makers and stakeholders explicitly evaluate information in one or more steps of the process of policymaking, program planning and management, or service provision. (6) In the Ethiopian context, the PMT is a team of multidisciplinary health workforce that is primarily responsible for data use. (11,12) Effective use of the data can enable targeted improvements in health service delivery to meet the population needs. (17) However, the strength and quality of the evidence needed to get valid information to make decisions about health programs is either weak or insufficient in many developing countries (18)(19)(20) mainly due to ineffective data use culture. (20) Inadequate infrastructure, leadership turnover, dysfunctional external relations (26), poor production of information and limited resources (15) were identified as major bottlenecks for information use. In addition to shortage of skilled workforce, imbalances in skill mix, geographical misdistribution, difficulty in inter-professional collaboration, inefficient use of resources, and burnout were found to affect health service quality. (21) So far, substantial efforts to strengthen health information systems mainly focused on digitization, improving data quality and analysis, and identifying problems, but the ultimate goal is using 4 information to solve problems, which requires building an information use culture over time. (22) Therefore, engagement (including involvement, commitment, effort or observable behaviour, positive effect or some combination of these) of healthcare leaders and managers is pivotal if we are to improve the Health Information System (HIS) and hence the health service delivery. (4,13) The engagement level and capacities needed by health managers and performance monitoring teams to respond to current and emerging issues are not yet well understood. (21) Without radical structural and systemic changes, existing governance structures and management systems will continue to fail to address the existing gaps in health service delivery. (2) Furthermore, despite large investments in performance monitoring team improvement in Ethiopia, a common performance renewal effort is lacking. There is paucity of studies about facilitators and challenges that influence the use of health data to improve primary health care delivery in LMICs. This study, therefore, is aimed at identifying experiences of the PMT, facilitators and barriers to information use process in healthcare facilities in Harari region and Dire Dawa city administration, Eastern Ethiopia.

Study Settings
The study was conducted in selected public health facilities of Dire Dawa and Harari regions.
Located 515 kilometers from Addis Ababa, Dire Dawa has an estimated population of 341,834, with 68.23% of them living in urban area. Data on public health facilities indicate that, there are about 15 health centers (8 urban and 7 rural), two hospitals, and 32 health posts under the city administration. There are a total of 622 health professionals and 209 health extension workers, and these health facilities serve a total of 480,000 people. Harar is a capital of Harari, one of the regional states of Ethiopia, and is located about 517Km east of Addis Ababa and 48 km south of Dire Dawa. According to the 2007 census, the region has a total population of 183,415 people, of whom 92,316 are men (23) and 54.18% living in urban area. (24) There are three government hospitals, one university teaching hospital, two private hospitals, eight health centers, and 24 health posts in the region.

Study Design
This study used a phenomenological study design. Consolidated Framework for Implementation Research (CFIR) framework to identify the most relevant constructs with the aim of describing data use approaches. The CFIR framework is an evidence-based framework drawing from multiple disciplines that provides a comprehensive arrangement of paradigms influencing complex implementations. The framework has five major domains (Inner setting, Outer setting, Intervention characteristics, Individuals involved and Implementation process) with associated components, all of which were used in this study.

Study Sampling and data collection
We conducted a key informant interview using a semi-structured interview guide. The tool was comprised of questions related to socio-demographic characteristics of the respondents, process of the PMT establishment and implementation strategy, data use processes and practices, barriers to data use, motivating factors for data use, and recommended mechanisms to improve the data use practice.
Two hospitals and four health centers were randomly selected from list of facilities in the two regions. A purposive sampling technique was employed to select the key informants. Eighteen interviews were conducted until data saturation is reached. Data were collected between July 05, 2021 and July 24, 2021 by interviewers fluent in local languages (Amharic and Afan Oromo) and English, with graduate level education and experience in qualitative data collection. All members of the data collection team undergone a one day training workshop to have a common understanding on the interview guide and objectives of the study. The data collection activities were supervised on daily basis by the study investigators. The key informants were PMT members of the health facilities including medical directors of hospitals, heads of health centers, heads of departments in the facilities (outpatient, inpatient, emergency, maternal and child health, pharmacy, laboratory, nursing, human resource and finance team leads), and the Health Management Information System (HMIS) officers. All interviews were conducted in private place suitable for the respondent and the interviews lasted about 20-60 minutes. 6

Data Analysis
The interviews were transcribed verbatim and field notes were expanded while on the field. The interviews were translated to English and again translated back to the original languages to confirm the accuracy of the meanings. A codebook was developed based on initial review of the transcripts and transcripts were systematically coded using ATLAS.ti software. Double coding was initially used with coding disagreements resolved by discussion and updates to the code definitions where needed. Double coding continued until no new disagreements were identified. Subsequently, summaries for each transcript were written under each code using a matrix. Thematic data analysis was used to describe and compare general statements as relationships and themes and sub-themes present on the data. Accordingly, findings were categorized into five themes. Under each theme, sub-themes were defined and verbatim quotes that represented opinions were applied to substantiate the results. Rigor was enhanced through regular discussions between researchers who read all interview transcripts, counter checked the transcripts, coded the data and agreed on the emerging themes and sub-themes. 7

Key Themes and Sub-themes
In this study five key themes and about 16 sub-themes have merged. The main themes and subthemes emerged from the study are presented in Table 1. Dawa Administration and Harari regional health bureaus, and the health facilities. Before data collection, informed written consent was obtained the study participants. Furthermore, participants has been assured of confidentiality of information and their right to withdraw from the study at any time during the study. In this paper, personal identifiers has been omitted to maintain confidentiality, while neutral identifier and age of the participants were mentioned in direct quotes.

Socio-demographic characteristics
A total of 18 in-depth interviews were conducted in two Hospitals and four health centers to explore the PMT experience, barriers and facilitators of data use. Of these participants, 8 were females, 3 were health facility heads, and they have median age (IQR) of 31 (7) years. (Table 2)

Membership and Roles of PMT at the health facilities
Participants reported that health facilities use certain criteria to select the members of the PMT. Planning, identifying gaps and intervening on the identified problems, and monitoring and evaluating specific activities.
The key informants further pointed out "…we select poorly performed activities and the responsible departments will design an action plan for the identified problems. Then the department will be directed to monitor the implementation of the action plan and they are expected to bring the progress in the subsequent meetings." (KI17, 35 years old) The modality of PMT meetings. Health facilities have monthly meeting plan in their health facilities which is prepared in advance on the annual plan. Respondents pointed out that the monthly meetings were conducted immediately after each unit submitted their monthly report. The focuses of PMT meetings reported include data quality, performance activities (monthly, quarterly or annual performance), service quality, and the service improvement strategies.
According to participants, the first agenda of the PMT meeting is evaluating the previous report, and then comparing it with the current performance. Afterward, the team develops an action plan based on the identified gaps. However, in some health facility the previous performance is not conducted at all.
"In our monthly PMT meeting, the first thing is presenting the monthly performance report for each unit. Based on the report, gaps and challenges are identified, before action plans are drafted on the identified gaps". (KI9, 29 years old) The PMTs mostly utilize routine data for evaluation and monitoring of service delivery programs.
There was no culture of using health related data from other sources such as surveys, assessments, research findings.
"In our health center, the main target of PMT is the routine data. The data accuracy and completeness are checked. Service improvement strategies are also discussed." (KI5, 26 years old) 13 The respondent further stated "data collected in our health facility is used for making decisions. I have not seen other data sources from researches or surveys being utilized so far." (KI5, 26 years old)

Major barriers to data use in the facility
The organizational barriers to data use at the facility level were poor data quality, being a member of many committees and high patient flow), human resource related issues, input related issues, inadequate budget allocation, as well as lack of performance based incentives. The quality of the routine data collected at health facilities has been reported as a barrier for effective data use.
14 "There is a gap in data quality including data inconsistency and incompleteness.
Healthcare providers perform their daily activity but they do not document it on the register regularly. The data from HMIS may contradict from your observation every day.
Hence it is difficult to use our data for decision making due to its poor quality." (KI2, 25 years old) Another participant further pointed out "A timely, reliable and high-quality data should be generated in order to use the data for decision making. Monitoring and supporting the staffs is also critical to obtain high quality data." (KI17, 35 years old) HIS Input related factors including shortage of patient registration was the other reason mentioned as barrier for data use. Budget constraint for effective data use at the health facilities was also an influence in the facilities.
"We use the budget which given for the health center, but there is no budget allocated specifically for HMIS." (KI6, 34 years old) Healthcare workers' work ethic and behavioural barriers were the other sub-theme emerged.
Poor commitment and lack of accountability from healthcare providers and PMT members were the most commonly reported challenges. One respondent explained the commitment and competing priorities of PMT members as "…sometimes we reviewed the same problem repeatedly without a solution. We start to get fed up and start to wonder when it will be solved. Sometimes, we skip the meeting intentionally for this reason. (KI9, 29 years old) Another respondent pointed out that: 15 "…health workers that reported incomplete or false data are not given any administrative punishments for their wrong doing." (KI18, 30 years old) Furthermore, lack of understanding of data value by healthcare workers was indicated as the major challenge faced when using data for action. Poor tracking of problems, and lack of monitoring of action plans is frequently observed according to the key informants.
"The main problem is that we don't strictly follow the action plans designed in the previous PMT meetings." (KI2, 25 Years old) Absenteeism and interruption due to competing priorities were also reported during PMT meetings.
" Others believe that incentive may not necessarily motivate staffs to use the data or improve service performance.
"It is hard to say that presence of incentives only positively affects data use.
Providing incentives before attitude change may even adversely affect the data use practice." (KI11, 32 years old) Demotivating factors for effective data use practices were cited by the study participants. The main demotivating factors include shortages of resources, inadequate salary, and inadequate follow up.
"Salary is one of the demotivating factors because it does not fit with the job we undertake." (KI10, 28 years old) "There is no follow up mechanism after trainings." (KI8, 25 years old) The leadership skill of the managers was one of the factors affecting data use in health facilities.
Health managers' and case-team/departments' poor leadership skills, and lack of value for data were also mentioned as demotivating factors.

Recommended motivation mechanisms for an improved data use
Performance-based recognition was recommended by all informants in this study as major motivation mechanism to improve data use. to improve data quality and use of information to regularly monitor progress and improve health service performance. (11,12) Although some irregularities were reported, the monthly meetings were conducted immediately after each unit submitted their monthly report and before submitting their report to the next level to monitor progress and improve performance. The MOH guideline indicates that the meeting dates, venue and its members should be officially communicated in advance and the meeting should be conducted at least a day ahead of submission of the monthly report to the next level. (11,12,25) The present study found that the major focus area of PMT meeting were data quality, performance improvement, and evaluation of previous action plans. Studies on this indicate, follow-up activities for gaps highlighted in the previous PMT meeting should always be the first item on the agenda, followed by an assessment of progress on those gaps. (12,25) Meetings and collected data have no value in themselves unless action items from meetings are implemented and data are analyzed into meaningful actions. (26) 20 Health facilities should design strategies to minimize the number of committees and integrate similar committees to improve their service provision. Most PMT members in our study were usually involved in at least two other committees in their health facility. This has its own share of poor follow up of activities set out by the PMT; being overburdened by committee meetings and assignments; creating fatigue and a shortage of time to accomplish PMT assignments.
Evidence indicate data triangulation through the use of other sources such as original research, community feedback, expert opinions, vital registration, censuses and routine HMIS data can yield better results. (12,25,26) Although there were practice of use of routine internal data, information use from external sources was limited.
Previous studies indicated that an organizational context that supports data collection, availability, and use, the technical aspects of data processes and tools, and the behavior of individuals who produce and/or use data are the main elements of health information use. (25,27) The major challenges of data use reported in the present study emanate from organizational, behavioral and technical sources including poor data quality, competing priorities, shortage of skilled human power, and lack of performance-based motivation for the health workers.
Healthcare organizations are increasingly required to gather and report data about their performance and respond to the results of consequential quality measurements. (28) Excellence in data quality enables healthcare organizations to plan and provide effective and efficient service for users and to meet their targets. (29) Our study revealed that the poor quality of data was one of the major challenges for an informed decision making. A mixed-methods study in Addis Ababa indicated that the PMT meetings that were designed for the sole purpose of improving data quality

Conclusion
This study has generated important insights into PMT establishment, its implementation strategy, barriers for data use and recommendations to enhance data use practice at a point of healthcare service delivery. The study found that most performance monitoring teams in health facilities were established and functioning according to the national standard. The study also underscored that barriers to effective data use include engagement of PMT with multiple committees, poor quality of data, lack of accountability, and poor documentation practices. Non-monetary incentives and recognitions for health workers were recommended as means of enhancing data use practice.
Improving the quality of routine data, integrating different teams into PMT, establishing accountability framework, and designing documentation methods have the potential to improve informed decision making. While comprehensive countrywide study of the PMT is required, policy makers, stakeholders working in HIS, and health managers should work on improving routine data quality, and design motivational strategies including recognition and non-monetary incentives to improve data use which has the potential to improve health service performance. There has been an increased need for strengthening health service performance to manage population needs through effective leadership (5-7) and improved health facility data use culture.
(8-10) The increasing demand for and capacity to use data appears more important than the augmenting supply of evidence (3,13) for improved access to and quality of care. (4,14) Collection, processing, transforming, communicating, and using service delivery reports and administrative records play a crucial role in decisions towards improved health outcomes. (15,16) Data use is the process through which decisions-makers and stakeholders explicitly evaluate information in one or more steps of the process of policymaking, program planning and management, or service provision. (6) In the Ethiopian context, the PMT is a team of multidisciplinary health workforce that is primarily responsible for data use.

Study Settings
The study was conducted in selected public health facilities of Dire Dawa and Harari regions.

Study Design
This study used a phenomenological study design. Consolidated Framework for Implementation Research (CFIR) framework to identify the most relevant constructs with the aim of describing data use approaches. The CFIR framework is an evidence-based framework drawing from multiple disciplines that provides a comprehensive arrangement of paradigms influencing complex implementations. The framework has five major domains (Inner setting, Outer setting, Intervention characteristics, Individuals involved and Implementation process) with associated components, all of which were used in this study.

Study Sampling and data collection
We conducted a key informant interview using a semi-structured interview guide. The tool was comprised of questions related to socio-demographic characteristics of the respondents, process of the PMT establishment and implementation strategy, data use processes and practices, barriers to data use, motivating factors for data use, and recommended mechanisms to improve the data use practice.  Subsequently, summaries for each transcript were written under each code using a matrix.
Thematic data analysis was used to describe and compare general statements as relationships and themes and sub-themes present on the data. Accordingly, findings were categorized into five themes. Under each theme, sub-themes were defined and verbatim quotes that represented opinions were applied to substantiate the results. Rigor was enhanced through regular discussions between researchers who read all interview transcripts, counter checked the transcripts, coded the data and agreed on the emerging themes and sub-themes.

Ethical Considerations
The Dawa Administration and Harari regional health bureaus, and the health facilities. Before data collection, informed written consent was obtained the study participants. Furthermore, participants has been assured of confidentiality of information and their right to withdraw from the study at any time during the study. In this paper, personal identifiers has been omitted to maintain confidentiality, while neutral identifier and age of the participants were mentioned in direct quotes.

Socio-demographic characteristics
A total of 18 in-depth interviews were conducted in two Hospitals and four health centers to explore the PMT experience, barriers and facilitators of data use. Of these participants, 8 were females, 3 were health facility heads, and they have median age (IQR) of 31 (7) years. (Table 1)

Key Themes and Sub-themes
In this study five key themes and about 16 sub-themes have merged. The main themes and subthemes emerged from the study are presented in Table 2.

Membership and Roles of PMT at the health facilities
In Ethiopia, PMT at health facilities is established based on the standards set by the Ministry of Health. In the present study, pParticipants reported that health facilities use certain criteria to select the members of the PMT. The main criteria reported to establish the PMT were being the head of the quality department, HMIS unit team leader, department head, management team, and staff with good performance. Roles and responsibilities of PMT members include using health data and in improvinge the health service performance. The specific roles include preparing action plan, putting directions to improve the service delivery, compare performance overtime, monitor monthly performance, provide feedback to various units, building capacity of health workers and preparing reports. The present study also found that the PMT members were aware of their responsibilities.
One of the participants stated that "…each member of the PMT is expected to prepare and submit their case team or department reports to the head of the health facility on time. All PMT members will discuss on the submitted report during the monthly PMT meeting in which the reports are crosschecked for its consistency and quality. When the achievements are lower than expected, the reasons for underachievement are sorted out and future directions are put to improve the performance." (EPI focal personKI4, 38 years old) The participants' opinions on the alignment of the PMT's roles and responsibilities at the facility with their activities were mixed. While the majority of respondents stated that PMT tasks and responsibilities are totally matched with their actual activities, some stated that they are not completely aligned with their actual activities. There is overlapping of duties and roles, according to these participants.

"As a case team leader, my responsibility is identify the challenges in my activities bur
sometimes the roles and activities rendered to us are not related to service performance and members get frustrated due to that" (KI16, 35 years old) 10

Relevance of PMT strategy and its implementation
The perceived benefits of PMT for the facility include improving the service delivery and customer satisfaction. This team is also vital for maintaining the well-functioningsharing experiences and skill among of the departments and case teams. Respondents understood the benefits of PMT for facilities, which include planning, identifying gaps and intervening on the problem, ensuring the facility's progress to success, and monitoring and evaluating program implementations.
"… the members of PMT are from different department; there is knowledge sharing on different topics including preparation of reports and how to improve service performance." (KI11, 32 years old) Planning, identifying gaps and intervening on the identified problems, and monitoring and evaluating specific activities.
The key informants further pointed out "…we select poorly performed activities and the responsible departments will design an action plan for the identified problems. Then the department will be directed to monitor the implementation of the action plan and they are expected to bring the progress in the subsequent meetings." (KI17, 35 years old)

The modality of PMT meetings.
Adequacy and convenience of time of PMT meeting is essential in order to identify the most important problems in the facility. In this study, tHealth facilities have monthly meeting plan in their health facilities which is prepared in advance on the annual plan. This annual PMT meeting schedule is usually posted in visible area. Moreover, rRespondents pointed out that reported that the monthly meetings were conducted immediately after each unit submitted their monthly report.
"Our PMT meeting is conducted on monthly basis. Immediately after the submission of the monthly report (usually at 21 st day of the month), we hold our PMT meeting at  On the other hand, it was indicated that the time allocated for PMT meetings was inadequate and inconvenient. All participants anonymously unanimously agreed that enough time should be assigned and convenient time should be allocated for PMT meetings. The focuses of PMT meetings reported include data quality, performance activities (monthly, quarterly or annual performance), service quality, and the service improvement strategies.
According to participants, the first agenda of the PMT meeting is evaluating the previous report, and then comparing it with the current performance. Afterward, the team develops an action plan based on the identified gaps. However, in some health facility the previous performance is not conducted at all.
A participant from a hospital stated "In our monthly PMT meeting, the first thing is presenting the monthly performance report for each unit. Based on the report, gaps and The quality of the routine data collected at health facilities has been reported as a barrier for effective data use.
"There is a gap in data quality including data inconsistency and incompleteness.
Healthcare providers perform their daily activity but they do not document it on the register regularly. The data from HMIS may contradict from your observation every day.
Hence it is difficult to use our data for decision making due to its poor quality." (HMIS Another key-informant stated "…due to COVID-19 the head of HMIS has been in quarantine for the last two months which negatively affected the PMT activities (KI3, 27 years old) "Capacity building on data quality and project development for the members of PMT has been a very good incentive since we never had such experience before." (KI7, 28 years old)

Recognition and Recognition and nNon-monetary incentive s The participants listed
several non-monetary incentive mechanisms that can motivate the PMT members in the facility were reported. The main non-monetary incentives awere provision of mobile cards, and recognition of good performers, as well as awarding the of best performing facilities based by regional health bureau. Participants also indicated that these motivational mechanisms become effective only as far as the information if they are directed towards improving the data use culture of the facilities is improved.
A participant suggested pointed out that "Performance-based recognition and motivation of staffs can improve the data quality and subsequently the data use in the facility." Others believe that incentive may not necessarily motivate staffs to use the data or improve service performance.
"It is hard to say that presence of incentives only positively affects data use.
Providing incentives before attitude change may even adversely affect the data use practice." (KI11, 32 years old) Demotivating factors for effective data use practices were cited by the study participants. The main demotivating factors include shortages of resources, poor quality of routine data, insufficient human power, and lack of accountability, inadequate salary, and inadequate follow up. Some study participants mentioned the follow up from Woreda or regional health bureau was not adequate.
"salarySalary is one of the demotivating factors because it does not fit with the job we undertake." (NCD focal personKI10, 28 years old) "There is no follow up mechanism after trainings." (KI8, 25 years old) The leadership skill of the managers was one of the factors to promote theaffcetingaffecting data use in health facilities. Health managers' and case-team/departments' poor leadership skills, and lack of value for data were also mentioned as demotivating factors.

Recommended motivation mechanisms for an improved data use
Performance-based recognition was recommended by all informants in this study as major motivation mechanism including p to improve data use., arranging meeting sites and time,  (12) In line with previous studies our study indicated that the primary responsibility of PMT was to improve data quality and use of information to regularly monitor progress and improve health service performance. (11,12) In line with the national guideline, aAlthough some irregularities were reported, the monthly meetings were conducted monthly immediately after each unit submitted their monthly report and before submitting their report to the next level to monitor progress and improve performance. The MOH guideline indicates that the meeting dates, venue and its members should be officially communicated in advance and the meeting should be conducted at least a day ahead of submission of the monthly report to the next level. (11,12,25) The present study found that the major focus area of PMT meeting were data quality, performance improvement, and evaluation of previous action plans. Studies on this indicate, follow-up activities for gaps highlighted in the previous PMT meeting should always be the first item on the agenda, followed by an assessment of progress on those gaps. (12,25) Meetings and collected data have no value in themselves unless action items from meetings are implemented and data are analyzed into meaningful actions. (26) Health facilities should design strategies to minimize the number of committees and integrate similar committees to improve their service provision. Most PMT members in our study were usually involved in at least two other committees in their health facility. This has its own share of poor follow up of activities set out by the PMT; being overburdened by committee meetings and assignments; creating fatigue and a shortage of time to accomplish PMT assignments.
Evidence indicate data triangulation through the use of other sources such as original research, community feedback, expert opinions, vital registration, censuses and routine HMIS data can yield better results. (12,25,26) Although there were practice of use of routine internal data, information use from external sources was limited. Previous studies indicated that an organizational context that supports data collection, availability, and use, the technical aspects of data processes and tools, and the behavior of individuals who produce and/or use data are the main elements of health information use. (25,27) The major challenges of data use reported in the present study emanate from organizational, behavioral and technical sources including poor data quality, competing priorities, shortage of skilled human power, and lack of performance-based motivation for the health workers.
Healthcare organizations are increasingly required to gather and report data about their performance and respond to the results of consequential quality measurements. (28) Excellence in data quality enables healthcare organizations to plan and provide effective and efficient service for users and to meet their targets. (29) Our study revealed that the poor quality of data was one of the major challenges for an informed decision making. A mixed-methods study in Addis Ababa indicated that the PMT meetings that were designed for the sole purpose of improving data quality are not effective. (30) Another qualitative study to explore the facilitators and barriers of digital health technology use also identified data quality as a potential barrier. Health professionals either do not consider recording and reporting data as part of their routine activities or they just give more priority to the clinical provision and lesser attention to data. (30) Although there is a need to make significant investments in workforce development and training (33), tackling of behavioral factors require interventions that go beyond simple trainings and should focus more on initiatives that enhances positive attitude towards data value. (25) The individual determinant of motivation among healthcare workers are altruism, attaining professionalism, educational opportunity, and being more experienced. (32) In the present study, it was indicated that health facilities use capacity buildings, and some form of non-monetary incentives to improve performance while most informants indicated dissatisfaction with the absence of such motivating mechanisms. Career development opportunities, in-service trainings, and regular recognition for good performance were also reported to be practiced at the health facilities.
Provision of inputs necessary for HIS such as laptops, internet modems; as well as awarding the best performing health facilities were other motivational methods. Since health professionals can be motivated by a range of extrinsic and intrinsic factors, policy makers need to look beyond traditional financial incentives when designing policies to improve health service performance.

Conclusion
This study has generated important insights into PMT establishment, its implementation strategy, barriers for data use and recommendations to enhance data use practice at a point of healthcare service delivery. The study found that most performance monitoring teams in health facilities were established and functioning according to the national standard. The study also underscored that barriers to effective data use include engagement of PMT with multiple committees, poor quality of data, lack of accountability, and poor documentation practices. Non-monetary incentives and recognitions for health workers were recommended as means of enhancing data use practice. Improving the quality of routine data, integrating different teams into PMT, establishing accountability framework, and designing documentation methods have the potential to improve informed decision making. While comprehensive countrywide study of the PMT is required, policy makers, stakeholders working in HIS, and health managers should work on improving routine data quality, and design motivational strategies including recognition and nonmonetary incentives to improve data use which has the potential to improve health service performance.